General practice is severely challenged at present. We have manpower shortages, high workload and low morale. Many of us have financially unviable practices, while simultaneously our specialty is threatened by financial exploitation from outside providers and those who would cherry-pick parts of what has traditionally been the remit of general practice. Many of us also feel threatened by regulators and taken for granted by our legislators.

Added to this we must endure an increasing level of hospital dysfunctionality, with growing waiting lists for everything and shortages of primary and community care services. This is a difficult environment in which to contemplate further change and complexity.

We now have on the horizon a particularly difficult and different type of challenge. What is the role of general practice and the wider healthcare system in helping women in crisis pregnancy, and providing care for those who currently choose medical and surgical termination outside our jurisdiction, and often in isolation? This is a discussion that needs to take place, albeit in the sub-optimal conditions that currently prevail in general practice.

The recent report of the Joint Oireachtas Committee on the Eighth Amendment to the Constitution has essentially changed the nature of the debate regarding abortion in Ireland. Previously, this debate has largely focused on balancing the rights and risks of mothers and babies in pregnancy, eg. fatal foetal abnormality and surgical termination. The report’s recommendations now firmly places  medical termination, general practice and general practitioners at the centre of this debate.

A diversity of viewpoints

The process by which we have reached the decision to hold a referendum is democratic, and representative of a societal opinion for change. GPs, a subset of the general population, have a diversity of viewpoints across the full spectrum of opinion. A referendum challenges us individually to inform ourselves, with accurate information, prior to making any decision. This referendum will also challenge us to have an opinion as to whether the issues raised by the referendum and its consequences constitute core general practice, special interest general practice or neither.

The Government has announced its intention to hold a referendum that will propose the repeal of the Eighth Amendment and provide for the termination of pregnancy in accordance with law. The details of the proposed legislation that would follow a vote in favour of repeal are not as yet known.

Many uncertainties

There are many uncertainties. Will the referendum be passed? What will the amending legislation look like and will it pass a Dail vote? What are the timelines to enactment of any new legislation? What process of discussion will take place to inform new legislation?

While our elected representatives have signalled a request to the medical profession for a very different landscape in crisis pregnancy management, for both medical and surgical terminations, the views of all medical and other relevant allied health professionals involved need careful and considered hearing. Legislation as recommended in the Oireachtas report must also be accompanied by measures and policies that will seek to address and minimise crisis  pregnancies, including comprehensive contraceptive services and sexual health education programmes.

From a general practice viewpoint, if the referendum passes, the design of care for crisis pregnancy must ensure  time-resourced, non-judgmental, safe, quality-assured consultations with clear integrated care pathways to secondary care for diagnostics or referral for other specialist care as necessary. 

Timely, comprehensive supportive counselling services need to be put in place. The design of crisis pregnancy services should exist irrespective of whether the GP is a prescriber of medical termination of pregnancy (MTOP) or not. Such consultations should be within the scope of the law, and allow for conscientious objection, in accordance with  Medical Council guidelines. Decisions should take place in the confines and privacy of the consultation, trusting and respecting the woman’s ultimate right to choose. There should be no lists of providers or non-providers of such services unless practitioners wish to disclose this themselves.

At this time, there is little evidence to suggest that Irish general practice will be different from other countries who currently allow for MTOP. Some recent polls suggest that while a majority of GPs are likely to support the repeal of the  eighth amendment, this would not necessarily translate into a majority in favour of a GP-delivered MTOP service. On either end of the spectrum, some doctors will be certain of their approach, but I suspect the majority are currently  struggling with uncertainty.

The final design

If the referendum passes, more detailed information will need to be gathered to inform legislators, and to enable the Department of Health, together with the postgraduate training bodies and representative bodies, to design comprehensively the detail and resourcing of such services post-referendum. While looking at this from a GP perspective, we need to be cognisant of the fact that our obstetric colleagues and our hospital services will also have to plan regarding surgical terminations, and also for failed or complicated  MTOP. The final design will need to be cross-sectoral and integrated.

While our legislators have made recommendations, the implementation will more complex.

General practice must be part of the debate. Individually and collectively we must inform ourselves for the decisions facing us. Careful use of language, respect, compassion, truth and trust are just some of the essential elements of the general practice conversation ahead.

I encourage all faculties to explore how best we, as GPs, can care locally for our patients faced with crisis pregnancy and assist them in reaching a decision as a matter of healthcare rather than of law. But first we must await the decision of the electorate.